Basic Information
| Provider Information | |||||||||
| NPI: | 1194896654 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEHAVIORAL HEALTH RESOURCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3857 MARTIN WAY E | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607047170 | ||||||||
| FaxNumber: | 3607094374 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W K ST | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985842939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604261696 | ||||||||
| FaxNumber: | 3604270357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 12/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 3602367170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/27/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 600144953 | WA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1993088 | 05 | WA | MEDICAID |